Resident Remediation
A Case Management Approach
modified from
AAMC/Group on Resident Affairs
Vancouver, B.C.
Kathryn M. Lane, Ed.D.
Vice President, Academic Affairs,
Maimonides Medical Center, Brooklyn, NY
Michael Bednarski, Ph.D., Consultant
Resident Remediation
Websters – “The act or process of
correcting a deficit.”
Resident Remediation
Is it the Institutions Responsibility?
Is Remediation the Institution’s
Responsibility? YES.
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An Educational Process
Commitment to Resident
Success/Development
We are Faculty/Mentors in
a Teaching Institution
Residents Have Different
Adaptive Styles
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It’s Humanistic
Produces More Effective
Doctors
Impacts Future Caring
Is Remediation the Institution’s
Responsibility? NO.
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Too Expensive
“They’re Adults – Should “Know Better!”
Experience with Remediation – “It Doesn’t Work!”
No Resources/Organized Institutional Resources
“Can’t Change Character, Attitude, Motivation.”
Natural Selection Theory – “Bad Apples Drop
Out.”
Resident Remediation
Whose Responsibility?
DIO?
Chair?
Program Director?
Chief Residents?
GMEC
Resident Remediation
Who, What, When, Where?
WHO SHOULD BE
REMEDIATED?
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Are There Residents that Should Not be
Remediated? Severity of Offense.
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Should Everyone Else be Remediated? If the
resident agrees to participate in remediation.
WHEN TO REMEDIATE?
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First Sign or Expression of Difficulty – Trust
Instincts – Unaddressed issues, performance,
demeanor - can become bigger problems later.
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Part of Formative Evaluation Process – Identify
Specific Behaviors
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Link Performance to ACGME Competencies
WHAT TO REMEDIATE?
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Proper Assessment
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Evaluated by qualified professional.
What is the primary problem?
Etiology Vs Symptomatology
Target Behaviors/Symptoms
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Performance Anxiety
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Tests, morning reports, rounds, conference.
Coping Deficits.
Transitional Adjustments.
Work/Life Balance.
Cultural Differences
Communication/Cognitive Style
WHERE TO REMEDIATE
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Within an Organized Process
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On Top of an Recognized/Organized Structure
AN ORGANIZED STRUCTURE
Maimonides Medical Center
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High Functioning, Responsive Alert System
Coherent/Understood Policies and Procedures
Centralized Management (Academic Affairs)
Available Resources
Elaborated Support Systems for Residents, Programs, and
PD’s
Follow-Through and Communications with Programs
Case Management – Using System Resources
Resident Integration/Reintegration with Structure
Safe Liaison
Remediation is Multi-factorial
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Varied Causes of Remediation
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Evaluation/Biases of Performance
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The need for remediation arises from many different
sources outside the resident. External events impact
resident performance.
How performance is assessed contributes to remediation
determinations.
Conceptual Issues in Remediation
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There exists a good deal of controversy on definitions
and goals of remediation.
Common Causes of Remediation
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Poorly Elaborated/Disseminated Policy
 No formal or enforceable policy in place.
 Policy inadequately communicated.
 Failure to follow protocol
Performance Issues
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Clinical Knowledge/Skills Deficits
Communications/Interpersonal Skills Deficits
Coping Deficits-poor help seeking skills
Mentoring/Learning Style Conflicts
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Communication Style
Cognitive Style-sensing vs intuitive, thinking vs feeling, judging vs
perceiving-introverted vs extraverted
Three Components of Resident
Performance Assessment
1)
Establishing Performance Criteria
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Use consensually established criteria
Establish standards with others (including residents)
Determine aspects of performance to be evaluated
 Codify-document performance criteria
Communicate criteria prior to performance
Establish understanding and compliance of
criteria.
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Elaborate the grievance (“disagreement”) proce
Three Components of Resident
Performance Assessment
2) Performance Evaluation
 Develop objective assessment methods
 Use multiple independent rates on similar
established criteria-then compare
 Use Resident self-ratings.
 Stick to Performance criteria – Avoid narratives.
 Establish and maintain records. Periodically review.
Three Components of Resident
Performance Assessment
3) Criteria-Based Performance Feedback

Criterion-referenced tests determine what learners can do and
what
they know, not how they compare to others. Criterionreferenced tests
report how well learners are doing relative to a predetermined performance level
on a specified set of educational goals or outcomes
included in the curriculum.
 Constructive/Formative
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Formative evaluation occurs throughout the clinical rotation and
allows for revision and improvement
Conceptual Issues in Remediation
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Correlate Faculty, Program Director Evaluations &
Resident Performance
Define the Goals of Remediation
Define Who Should Participate and Who is
Responsible
Evaluate the effectiveness of Remediation for
Immediate and Lasting Change
Environmental Factors Affecting
Resident Performance

Structural Issues in the Department – Work flow, scheduling, and
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Leadership
staffing concerns that directly, negatively affect resident performance.
 Process Issues in the Department – Proper flow of
communications. Adequate and effective meetings. Established
expectations and performance guidelines. Adequate and timely
performance feedback. Peer relationships and initiatives for morale
development. Effective role-modeling.
 Departmental Communications/Interpersonal Skills – Naturally
occurring personality differences between residents, peers, and mentors
which become obstacles to resident performance
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Infighting, Role-Confusion, Morale
Resource Allocation
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Role Diffusion
Personal Factors Affecting Resident
Performance
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Motivation/Attitude
Coping Style
Cognitive Style
Personal History – Schemas/Transference
Anxiety
Idiosyncratic
 Environmental
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Hierarchy of Resident Response to
Remediation
How Remediation is structured and presented to
Residents effects outcomes.
Events, interactions, quality of feedback and goals
influence interpretation and response.
Hierarchy of Resident Response to
Remediation
1.
Corrective/Educational Experience
Most Adaptive
Present as opportunity for growth and learning.
Provides opportunities to reassess and adjust
Interpreted as constructive and developmental
Incorporate Into Behavior Change
Hierarchy of Resident Response to
Remediation
Situational Crisis
Somewhat Adaptive
Evokes positive and negative reactions
followed by adjustment and compliance
Regroup, Recover, Adapt and Comply
2.
Hierarchy of Resident Response to
Remediation
Blow to Self-Esteem
Maladaptive
Engages maladaptive coping, defenses, and erosion of
performance. Backfires.
Maladaptive Coping skills = Avoidance,
Withdrawal, Engagement (aggression)
Defenses = Denial, Rationalization, Projection
Erosion of Performance
3.
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Performance Anxiety Loop – “Under the microscope.”
Promoting Effective Remediation
Complimentary Approaches
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Institutional
Interpersonal
Psychosocial
Promoting Effective Remediation
Institutional
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Obtain Institutional Buy-In
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Involve Academic Affairs, DIO.
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Conducts/Manages the Remediation
Outlines/Serves Interests of All Parties
Ensure all Understand Protocol/Process
Specificity Objectives
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Identify Specific/Actionable Problems
Identify Specific Interventions
Promoting Effective Remediation
Interpersonal
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Avoid/Stem Character Judgments/Diagnosing
 Character Judgments – Put learners on the
defensive, close down learning, increases
projection
Frequent Constructive Feedback
Avoid Rumor Mill
Assess/Provide Support System
Promoting Effective Remediation
Psychosocial
Attends to the psychological needs and resources
important to resident development in the
remediation process
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Engage Stakeholders
Ensure Understanding of:
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Cause & Effect
Process
Desired Outcomes
Ramifications
Assess Emotions – Normalize Anxiety
Engage Ego – Corrective Experience
Assess Cognitive/Communication Styles
Assessing Resident Performance
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Take a Good History
Find Sources of External Validation
Avoid Biases
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Halo Effect
Central, Lenient, Strictness
Contrast Effect
Helping Residents Manage
Remediation
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MBTI Assessment
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Coping Style
Communication Style
Cognitive Style
Strength-Based Approach
Sources of External Validation
Interdepartmental Collaboration
Frequent Constructive Feedback
CONSRUCTIVE FEEDBACK
Is a Process
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Given with Care: Show genuine concern, try not to
insult or offend the resident.
Directly Expressed: Express feedback directly and
specifically. Deal clearly with particular incidents
and behavior. Do not “Tiptoe” around issues. Be
direct, open, and concrete.
Expresses Feelings: Express feelings as well as
issues so resident can gauge the full impact of
his/her behavior.
Avoids Evaluative Judgments: Simply describe the
situation as you see it, and let the person concerned
make the evaluation.
CONSRUCTIVE FEEDBACK
Is Concrete
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Involves Timing:
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Give when the resident is more open to it and not far
removed from the particular event(s).
Do not let issues build-up and get expressed out of
frustration.
Performance problems often fester due to lack of
timely feedback (performance difficulties only
become problematic after they have progressed too
far).
Give feedback on as many occasions as possible.
CONSRUCTIVE FEEDBACK
Is Actionable
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Center on behavior that can be changed, not
matters outside the resident’s control.
Suggest alternative ways of behaving.
Help him/her to think about new ways of
tackling old problems.
CONSRUCTIVE FEEDBACK
Is Clarified
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Check to see if resident understands
feedback
Check to see if resident can offer new
approaches to problems.
Clarify that you are both “on the same
page.”
Cultural Factors Affecting Resident
Performance
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Language Barriers
Help-Seeking Behaviors
Customs
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Deference
Cases You Will Encounter
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The Culturally Isolated Resident
The scapegoat
The Difficult Cognitive/Communication Style
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Big picture thinker
The introverted type
The logical type
The big-hearted type
The Anxious Resident
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The over-achiever
The perfectionist
The End
Download the post test questions
and return completed post test to
Dr. Sandra Oliver
Post Test One
1.
Which of the follow is incorrect regarding
Resident Remediation?
1.
2.
3.
4.
Remediation is Humanistic
Remediation Produces More Effective Doctors
Remediation Impacts Future Caring
Remediation is only the Resident’s
responsibility
Post Test Two
2.
Which of the follow is incorrect?
1.
2.
3.
4.
All residents should be remediated.
At the first sign of difficulty residents should
be remediated .
Remediation should be apart of a formative
evaluation process
Resident performance should be linked to
ACGME Competencies
Post Test Three
3.
Components of Resident Performance
Assessment include all the following except:
1. Establishing Performance Criteria
2. Performance Evaluation
3. Criteria-Based Performance Feedback
4. Norm Referencing of Resident performance
Post Test Four
4.
Constructive Feedback includes all of the
following except:
1.
2.
3.
4.
Given with Care
Integrates Evaluative Judgments
Directly Expressed
Is Clarified.